2019_Rippe.pdf

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Addressing Prenatal Breastfeeding Self-efficacy and Advancing the Baby Friendly Hospital Initiative

with HUG Your Baby Curriculum

By Molly Rippe

Senior Honors Thesis School of Nursing

University of North Carolina at Chapel Hill

March 22, 2019

Approved by:

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Foreword

My past experience as an educator and my work as a doula inspired me to complete an honors project. One of my favorite aspects of being a doula are the prenatal appointments with clients. My first degree is in education, and yet it wasn’t until sitting in homes with families, teaching about childbirth, that I felt like the teacher in me came alive.

I was introduced to the HUG Your Baby (HYB) curriculum during my maternal-newborn nursing course in the fall. Its content and videos spoke to me because of its ease of explanation about newborn behavior and cues. I had the chance to sit down with HYB’s creator, Jan Tedder and discuss HYB’s applications and previous research with the curriculum. Jan’s enthusiasm was infectious, and I could see how important the content could be for new families wanting to know more about their newborn.

In order to do further research with HYB, I completed all of the HYB online courses for professionals, including becoming a HUG certified teacher. Furthermore, I began developing ideas for implementing its curriculum into prenatal childbirth education courses for expectant parents. Through a review of the literature, I found current recommendations in support of breastfeeding, and I knew that HYB could offer simple, straight forward education on this topic. Since NC Women’s Hospital is a Baby-Friendly designated hospital, I was curious about the extent to which breastfeeding was emphasized prenatally in its affiliated childbirth education courses.

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began to consider the benefits of more focused breastfeeding education for clients giving birth at a Baby-Friendly hospital. Not only does the research demonstrate the correlation between prenatal breastfeeding education and increased rates of breastfeeding but adding this could ease the load of teaching on the busy nursing staff during postpartum recovery. I found myself wishing that these clients had the HYB DVD in their rooms to watch, and to take home with them. However, I knew that I wanted to start by introducing HYB prenatally.

Once the ideas for my research solidified, I began by applying for a scholarship to fund my research and received the Gump Family Undergraduate Research Award. I met with Jamie Conklin in the Health and Sciences Library who guided me in my literature search. I researched several breastfeeding self-efficacy scales, and contacted the creator of the one that most aligned with what I wanted to test. The author, Kristen Wells, granted me permission and sent me files of the assessment scale in its entirety. In addition to the ongoing support I received from my

advisor, I consulted with professor Maureen Baker in the School of Nursing about my research design and survey development.

In reaching out to the Women’s Health Information Center at UNC Medical Center, I gained support from the director to develop a HYB breastfeeding component that could be added to the standard childbirth preparation class. I observed instructor Chelsea Robinson’s (LCCE) 12-hour childbirth preparation training course and began talking with her about my idea for a pilot study. I also observed Jan Tedder teach a training course using HYB for childbirth

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I ran the pilot study over the course of a few weeks, so that data was collected with both an intervention and control group. With each group, I introduced myself, the study, and the voluntary pre-and-post survey. For the intervention group, I taught the breastfeeding portion of the course as a HYB certified teacher. After teaching and collecting the data, I organized the results and inputted all data into excel spreadsheets. Through consultation with Chris Wiesen of the Odum Institute, I was able to implement statistical analysis of the Prenatal Breastfeeding Self-Efficacy Scale (PBSES) data. Additionally, I analyzed the intention scale and other demographic data, organizing them into tables for ease of interpretation. Lastly, I wrote the following manuscript as a draft of the pilot study for submission to the Journal of Perinatal Education, or another similar peer-reviewed journal.

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Abstract

Experts recommend exclusive breastfeeding for at least the first six months of life. The World Health Organization’s (WHO) Baby-Friendly designation has significantly impacted rates of breastfeeding initiation in hospitals across the United States. However, exclusive breastfeeding rates at six months are still far below the WHO’s recommendations. Additional interventions to increase breastfeeding success are needed. A non-randomized, blinded experimental pilot study was designed to test whether participants in a standard childbirth preparation course offered at a Baby Friendly hospital differed in breastfeeding intention and self-efficacy from participants who took the same course with an added breastfeeding component from the prenatal education program called HUG Your Baby (HYB) (n=15). Breastfeeding intention and prenatal

breastfeeding self-efficacy scales were used and analyzed using a pre-and-post-test design. Results included an increased level of breastfeeding intention and self-efficacy in the

intervention group when compared to the control group. Implementing HYB curriculum may further support the Baby-Friendly Hospital Initiative and increase rates of successful

breastfeeding.

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Addressing Prenatal Breastfeeding Self-efficacy and Advancing the Baby-Friendly Hospital Initiative

with HUG Your Baby Curriculum Breastfeeding Recommendations

Research describes the extensive benefits of breastfeeding to both mom and baby throughout the lifespan. The World Health Organization (WHO), United Nations International Children’s Emergency Fund (UNICEF), and American Academy of Pediatrics (AAP) all recommend and recognize the importance of exclusive breastfeeding (EBF) for at least the first six months of life (Levy & Ashley, 2018). Exclusive breastfeeding means feeding a newborn only breastmilk, and no other food or water (World Health Organization, 2018b). WHO and UNICEF created the Baby-Friendly Hospital Initiative (BFHI) to enhance breastfeeding rates around the world through supportive environments and educational services (Munn, Newman, Mueller, Phillips, & Taylor, 2016). Research shows that incorporating the Ten Steps to

Successful Breastfeeding of the BFHI has the biggest impact on increasing rates of EBF at six months after birth (Kim, Park, Oh, Kim, & Ahn, 2018). The WHO nutrition target for 2025 is to increase EBF rates in the first six months of life to 50% (World Health Organization, 2014).

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The BFHI is one way in which hospitals can engage in measures to increase the nation’s rates of breastfeeding and EBF.

Baby-Friendly Hospital Initiative

The US has embraced the BFHI ethos through individual hospital designation that requires rigorous planning and implementation of structural changes. To become designated, facilities providing maternity and newborn services must initiate the Ten Steps to Successful Breastfeeding, which include policies and procedures outlining how to best support breastfeeding (World Health Organization, 2018c.) North Carolina Women’s Hospital earned the designation of Baby-Friendly in 2012 and is currently the only hospital in the triangle region with this designation. The third step in the Ten Steps to Successful Breastfeeding requires that hospitals “inform all pregnant women about the benefits and management of breastfeeding” (Baby-Friendly, 2018). Through this step, there is continual need for improvement of prenatal

breastfeeding education. Evidence demonstrates that increased education and support during the prenatal and postpartum periods is associated with increased rates of successful and exclusive breastfeeding (World Health Organization, 1998).

Interventions to Increase Breastfeeding

A review of the literature generated many studies that examine various interventions that increase rates of breastfeeding. A recent systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to understand the best intervention strategies to support the WHO’s recommendations for EBF (Kim, Park, Oh, Kim, &Ahn, 2018). This study encompassed 36,051 mothers and 27 RCTs. It includes three main conclusions 1. That BFHI is the best way to support EBF; 2. there is a critical need for additional prenatal and postpartum long-term

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would enhance the effectiveness of interventions (Kim, Park, Oh, Kim, &Ahn, 2018). Other findings in this meta-analysis associated interventions with the greatest impact on EBF at six months were those that liaised between the community and hospital, began prenatally and lasted after birth, used educational strategies that aimed to boost mother’s confidence and intention to breastfeed, and included breastfeeding support within the first week postpartum (Kim, Park, Oh, Kim, &Ahn, 2018). Additionally, studies showed that if the mother lacked confidence, self-efficacy, and support from partner and family, felt embarrassed or that breastfeeding was culturally unacceptable there was a reduced likelihood of breastfeeding initiation and continuation (Levy & Ashley, 2018).

Evidence suggests that higher levels of self-efficacy in women may increase the time that they exclusively breastfeed (Chan, Ip, & Choi, 2016). This research is grounded in the theoretical framework of social cognitive theory by Albert Bandura (Bandura, 1986). Social cognitive theory explains human functioning in terms of behavior, personal factors, and environmental events (Wells, Thompson, & Kloeblen-Tarver, 2006). This framework is a useful application to study breastfeeding as a health behavior because success with breastfeeding is determined by all three of these factors. Self-efficacy is part of the social cognitive theory and has been used to examine many health behaviors (Wells, Thompson, & Kloeblen-Tarver, 2006). Self-efficacy is the belief in oneself to attain something and promotes the idea that if one believes they are able to do something then one has a better chance of success in attaining it.

The WHO wrote in Evidence for the Ten Steps to Successful Breastfeeding (1998) that education during the prenatal period is most effective if it incorporates discussion of

breastfeeding myths and inhibitions, offers practical demonstration to increase skills and

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type of support that facilitates the initiation of breastfeeding can be learned prenatally through confidence building and knowledge acquisition (Schreck et al., 2017). Additionally, attitudes towards the normalization and observation of breastfeeding have been shown to help increase rates of breastfeeding (Meedya, Fahy, Kable, 2010).

HUG Your Baby Curriculum

HUG Your Baby (HYB) is an acronym for “help, understanding, and guidance” for young families. It is a multicultural, evidence-based, inclusive, and Baby-Friendly educational curriculum (HUG Your Baby, 2019). The Roadmap to Breastfeeding Success program, a component of HYB, covers not only effective breastfeeding parent education, but also offers continuing education training for professionals through a certification course with HYB. This training program integrates child development theory to understand newborn behavior and cues, as well as evidence-based recommendations in lactation support, and information that supports the BFHI breastfeeding goals (Tedder, 2015).

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Pilot Study Project

The purpose of this study is to determine whether teaching breastfeeding with the HYB curriculum during a prenatal childbirth class increases self-efficacy for, knowledge about, and intention to breastfeed. This pilot study measures intention and self-confidence in breastfeeding using a prenatal breastfeeding self-efficacy and intention to breastfeed scales.

Methods

Setting

Childbirth preparation classes affiliated with this project are taught at NC Women’s Hospital, a large academic teaching hospital with around 4,000 births annually situated in the southeastern United States. The childbirth education class is focused on normal physiological birth and is intended for expectant parents. Participants learn coping techniques for labor, typical interventions used in the NC Women’s Hospital setting, and knowledge about the process of labor and birth. Breastfeeding information is not considered a central part to the course. The fee for the course is $85 and it is open to the public, regardless of where one is giving birth.

Discounts are available to health center affiliated employees and students, as well as for

individuals covered by public insurance (UNC Medical Center, 2019). The training is 12-hours and takes place over the course of two sessions, typically over two weekend days. Each

instructor is a Lamaze Certified Childbirth Educator (LCCE) (UNC Medical Center, 2019).

Design

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breastfeeding curriculum as a component of the childbirth course (intervention). All 16

participants voluntarily enrolled in the study, completing a survey before the course and after the 12-hour childbirth preparation course was complete. Participants had the same childbirth

instructor and format and were blind to whether or not they received the intervention on

breastfeeding teaching. All participants who completed the 12-hour class were including in this pilot study. One participant was lost from the intervention group due to not completing the childbirth preparation course.

The pre-and post-survey included a valid and reliable prenatal breastfeeding self-efficacy scale (PBSES) as well as a scale of intention to breastfeed. The PBSES is a 20-item, five-point Likert-type scale. Permission was obtained from the author of the PBSES to use the tool before implementation. Its self-efficacy measurement is comprised of four themes: “(1) confidence regarding the skills and demands required for breastfeeding or extracting breastmilk using a breast pump; (2) confidence regarding gathering information about how to breast-feed; (3) confidence regarding breast-feeding around other people and feelings of embarrassment during breastfeeding; (4) confidence regarding social pressure when breast-feeding” (Wells, Thompson, & Kloeblen-Tarver, 2006, p. 185). The intention scale came from the HUG certified teacher training modules. This scale represented numbers one through ten, where one represents ‘I do NOT want to breastfeed’, and ten represents ‘I WILL breastfeed no matter what.’ In addition to the numerical scale, participants were given a chance to write down why they chose this number on the intention scale.

Appropriate Collaborative Institutional Training Initiative (CITI) modules were

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Intervention

Pregnant women in the intervention group completed the pre-survey (Appendix A) at the beginning of class and the post-survey (Appendix B) after the breastfeeding curriculum was complete. This curriculum was developed and taught by a HUG certified teacher and was based on introducing the concept of BFHI and the Roadmap to Breastfeeding Success program. As an introduction to the subject, the instructor asked for participation from the group, asking if anyone was planning on giving birth at NC Women’s Hospital because of its Baby-Friendly status. When none of the participants were familiar with BFHI, the instructor introduced the concept. The description included the significance of the designation and how BFHI designated facilities support women and families in breastfeeding.

Further participation was elicited when the instructor asked for stories participants have heard about breastfeeding. From this discussion, the class covered common breastfeeding concerns and myths including 1. pain, proper latch, seeking help at the moment of a question rather than waiting; 2. lack of milk supply and the research surrounding the rare occurrence of this, as well as the size of a newborn’s stomach using visual props, skin-to-skin and initiating breastfeeding in the first hour of life; 3. Returning to work, less missed days of work because of baby’s strong immune system, and overall health benefits of breastfeeding for mom and baby.

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breast-prop. At the conclusion of the breastfeeding educational intervention, the instructor asked participants to consider if there are people in their lives who would be helpful to them during their breastfeeding experience. The class was also asked to think of others in their lives who would not be supportive of their breastfeeding. The UNC lactation service number was displayed on the screen for everyone to note. The instructor encouraged all participants to consider

someone they can call, including a lactation consultant, when they need breastfeeding support after their birth.

Following the completion of post-intervention surveys, expectant parents received gifts for participating: a HUG DVD, a printout of the Roadmap to Breastfeeding Success (see Figure 1), a HYB pamphlet called Understanding and Caring for your Newborn (see Figure 2), and a newborn sleep sack to promote safe infant sleeping.

Demographics and Data Collection

Demographic data was voluntarily collected from the participants of this study (Table 1). None of the participants had given birth previously. The women’s ages ranged from 24-38 years old, and all were married and had partners present during the class. All participants had earned at least a bachelor’s degree, with the highest level of education at a PhD level. The majority had never taken a breastfeeding course previous to this childbirth training. Participants were also asked if they had relatives or friends that breastfed.

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preemptively, increases likelihood for one to continue breastfeeding (World Health Organization, 1998). At the conclusion of the survey, participants were given the option to opt-out of receiving HYB postpartum e-newsletters from the time of their estimated due date. There was a short paragraph included about the creator of HYB, and the general contents that the e-newsletter would provide.

TABLE 1. DEMOGRAPHICS OF THE SAMPLE

Characteristics Control, n (%) Intervention, n (%) Age (years)

20-30 2 (25) 3 (42.9)

>30 6 (75) 4 (57.1)

Any children?

No 8 (100) 7 (100)

Yes 0 (0) 0 (0)

Highest level of education

Bachelor's 2 (25) 2 (28.5) Master's 3 (37.5) 3 (42.9)

PhD 3 (37.5) 2 (28.5)

Marital status

Single 0 (0) 0 (0)

Committed

relationship 0 (0) 0 (0)

Married 8 (100) 7 (100)

Friend who breastfed?

No 0 (0) 0 (0)

Yes 6 (75) 6 (85.7)

Relative who breastfed?

No 1 (12.5) 0 (0)

Yes 7 (87.5) 6 (85.7)

Taken a breastfeeding class before?

No 5 (62.5) 6 (85.7)

Yes 3 (37.5) 1 (14.3)

TABLE 1. Statistical Analysis

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individually and combined. Results are labeled as follows: skills and demands, gathering information, breastfeeding around others, social pressure, and total self-efficacy measured (see Tables 4-8). Numerical data from the intention to breastfeed scale and descriptive data from the explanation of chosen number were also compared in pre-and-post surveys as well.

Results

Analysis revealed a change in participants’ self-efficacy in both the control and intervention post-surveys. The two largest differences between the control and intervention groups for the factors of self-efficacy were in the skills and demands section, and the gathering information section. Furthermore, when you compare the total self-efficacy measurement between the control and intervention groups, the intervention groups had higher rates of total self-efficacy.

Both the intervention and control groups scored high on intentions to breastfeed. There was not a significant difference in the data before and after the childbirth course as to ‘how sure’ participants were that they would breastfeed. For example, in the control group participants’ answers ranged from seven to ten on the pre-survey intention scale, and eight to ten on the post-survey, where 63% of the answers had no change from the pre-survey to the post-survey. In the intervention group, answers ranged from eight to ten in both the pre-and-post surveys,

accounting for 71% of the participants that had no change in their intention to breastfeed scale. Details of the qualitative data collected on intention to breastfeed scale are reported in Tables 2 and 3.

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TABLE 2. CONTROL GROUP DATA COLLECTION

PRE - how sure are you that you want to breastfeed? POST - how sure are you that you want to breastfeed? PRE-explain why you chose

this number

POST-explain why you chose this number

PRE - How long do you intend to breastfeed? POST - How long do you intend to breastfeed?

PRE - who will you call/reach out to for breastfeeding support? POST- who will you call/reach out to for breastfeeding support?

9 10 healthy for baby, bonding. Unless issues, I will breastfeed health benefits, bonding 6-12 months 6-12 months books, parents, friends, pediatrician, nurses probably at some point

10 9 want to try my

best to breastfeed

1 year 1 year counselor lactation consultant

9 9 I feel confident I

can make it

I don’t know

I don't know at the moment

my mother, my sister

maybe

7 9 plans are to breastfeed as long as baby responds well and grows properly

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TABLE 2. (CONTINUED)

PRE -how sure are you that you want to breastfeed? POST - how sure are you that you want to breastfeed? PRE-explain why you chose this number POST-explain why you chose this number

PRE - How long do you intend to breastfeed? POST - How long do you intend to breastfeed?

PRE - who will you call/reach

out to for breastfeeding

support?

POST- who will you call/reach out

to for breastfeeding

support?

9 9 I will try my best to breastfeed but I understand there may be limitations and will not put myself or baby under unnecessary stress

I plan to breastfeed and will exhaust all support options available to me to achieve this goal. But I understand there may be

situations where supplementation is needed.

1 year 1 year lactation consultants/ support groups lactation consultant, support groups, friends, family

8 8 Won't

sacrifice my sanity in the long term if my body just is not doing it

I will go to pretty great lengths to breastfeed but if my body just proves not capable, etc. then I'm okay with formula feeding 6 months- 1year 6 months- 1year

LC lactation

consultant, online groups

9 9 knowledge that it is better for baby if possible

it is beneficial to my baby's health

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PRE -how sure are you that you want to breastfeed? POST - how sure are you that you want to breastfeed? PRE-explain why you chose this

number

POST-explain why

you chose this number

PRE - who will you call/reach out

support?

10 10 I believe it's very important to breastfeed in terms of health of baby, bond, relationship, etc.

I am sure I want to breastfeed my baby because I know it provides great nutrition for baby as well as a great emotional bond.

as long as what is comfortable for baby and for me

as long as my baby needs it and we are both comfortable

UNC lactation consultants/support

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TABLE 3. INTERVENTION GROUP DATA COLLECTION

PRE - how sure are you that you want to breastfeed?

POST - how sure are you that you want to breastfeed?

PRE-explain why you chose this number

POST-explain why you chose this

number

PRE - who will you call/reach

out to for breastfeeding

support?

9 10 good for baby 6months - 1

year 6-12 months lactation consultation lactation support

9 9 I know problems can unexpectedly come up and I want to do what is best for baby

I know there are always going to be things outside my control

~1 year ~1 year friends, family, Dr.

sister in law, mother in law, lactation "Warm"-line, doctor

8 8 want to BF, not militant about it.

want to but know fed is best.

6-12 months

mom / friends lactation consultant, friends/family

8 8 I know it's the best way to give baby nutrition. I also know it may be hard or unforeseen

challenges and I'm okay with that.

It's proven to be most beneficial. However, if a circumstance arises I will be okay with formula.

As long as I can

as long as I can. Maybe stop around 1 year

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PRE - how sure are you

that you want to breastfeed?

POST - how sure are you that you want to breastfeed?

PRE-explain why you chose this

number

POST-explain why you chose this

number

PRE - How long do you intend to breastfeed? POST - How long do you intend to breastfeed?

PRE - who will you call/reach

out to for breastfeeding

support?

POST- who will you call/reach out to for breastfeeding

support?

10 10 It is important to me to have this

connection with my baby and to give them all the benefits gained by breastmilk

I am very interested in having the bonding time with my baby. I will also have great support from my partner, family, and friends.

12+ months 12+ months friends, family, lactation consultant family, doctor (primary care), lactation consultant, facebook group (attached at the nip)

9 10 I expect to breastfeed 8 months 9 months

10 10 health, cost Benefits to the baby (health) and bonding

12 months and pumping while at work

1 year support line at UNC

# provided - warm-line at UNC

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TABLE 4. SKILLS AND DEMANDS

Label Estimate

Standard

Error DF t Value Pr > |t|

Pre-Control 23.5000 1.5708

Pre-Intervention 25.8095 1.6793

Post Control 26.5000 1.5708

Post Intervention 29.5714 1.6793

Control: Post vs. Pre 3.0000 1.1701 13 2.56 0.0236

Intervention: Post vs. Pre 3.7619 1.2509 13 3.01 0.0101

Interaction 0.7619 1.7128 13 0.44 0.6638

TABLE 4.

TABLE 5. GATHERING INFORMATION

Label Estimate

Standard

Error DF t Value Pr > |t|

Pre-Control 20.2500 0.8097

Interaction 1.0714 0.7890 13 1.36 0.1976

TABLE 5.

TABLE 6. BREASTFEEDING AROUND OTHERS

Label Estimate

Standard

Error DF t Value Pr > |t|

Pre-Control 16.5000 0.8692

Interaction -0.2857 0.8782 13 -0.33 0.7501

TABLE 6.

TABLE 7. SOCIAL PRESSURE

Label Estimate

Standard

Error DF t Value Pr > |t|

Pre-Control 9.8750 0.3712

Control: Post vs. Pre -0.1250 0.2101 13 -0.60 0.5620

Interaction 0.5536 0.3075 13 1.80 0.0951

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TABLE 8. TOTAL SELF-EFFICACY MEASURED

Label Estimate

Standard

Error DF t Value Pr > |t|

Pre-Control 70.1250 2.7120

Interaction 2.1012 2.3451 13 0.90 0.3865

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Discussion

The PBSES and intention scales were utilized to examine whether teaching breastfeeding with the HYB curriculum during a prenatal childbirth class was associated with an increase in self-efficacy for, knowledge about, and intention to breastfeed. High rates of self-efficacy are related to initiation and continuation of exclusive breastfeeding (Meedya, Fahy, & Kable, 2010). PBSES results revealed a positive effect on the participants’ breastfeeding self-efficacy. Rates of self-efficacy were highest in self-confidence about skills and demands of breastfeeding, as well as the ability to find information and use resources to gain support for breastfeeding when needed. In a culture that is saturated with information, knowing where to find evidence-based, reliable information can be challenging. In this way, using the HYB curriculum prenatally gives expecting and new parents information they know they can trust and rely upon, as well as resources to turn to in moments of struggle after baby arrives. In addition, providing expectant parents with this information prenatally helps to create realistic expectations of what

breastfeeding may involve.

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through the built-in newsletters that arrive for the first 12 months postpartum. These e-newsletters help to support breastfeeding and reinforces information that parents learned prenatally. Content includes information on normal newborn behavior and cues, which when paired with breastfeeding support, aids in new parents’ ability to understand and communicate with their newborn. Links to YouTube videos demonstrate proper latch, hand-expressing milk, as well as other common issues in breastfeeding (Hug Your Baby, 2019). Recent systematic review and meta-analyses show that the combination of prenatal education with postpartum support is the key to increasing exclusive breastfeeding rates in the U.S. (Kim, Park, Oh, Kim, & Ahn, 2018). It is through a multi-pronged approach both in the prenatal and postpartum periods that HYB curriculum provides various interventions to help parents succeed in breastfeeding.

This study demonstrates an increase in self-efficacy in new and soon-to-be parents, offers practical demonstrations through teaching and videos, and involves the mothers’ social

supporters. Because of its multi-pronged approach, the curriculum is a well-rounded, beneficial tool that should be used. HYB curriculum may increase exclusive breastfeeding rates and should be considered when a hospital is in the process of becoming Baby-Friendly. Additionally, the HYB content and resources has the potential to reach beyond prenatal courses or Baby-Friendly hospitals. Only a small portion of expectant parents attend childbirth education classes, and the HYB resources such as the DVD, roadmap to breastfeeding success, and e-newsletters lend itself easily to settings outside the classroom. The transferability of the HYB curriculum across

settings is an asset and should be used to its fullest potential.

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also only included English-speaking participants enrolling in childbirth preparation classes. Since HYB is translated into several languages, future studies should include sharing the curriculum in languages other than English.

Another aspect of this project that would be better tested in larger and more diverse groups is the intention to breastfeed scale. All the women came into this course with very high levels of intention to breastfeed, even without high levels of knowledge about and self-efficacy for breastfeeding. The intention scale did not prove to be a helpful marker in this population but would still be an important assessment tool to keep in the study for other populations.

Future studies should consider follow up with participants during the postpartum period. Self-efficacy and intentions could be compared to actual breastfeeding experiences and rates. Such findings may provide greater understanding of the impact of the multi-modal interventional approach of the HYB curriculum as it relates to exclusivity of breastfeeding at various time-markers in the postpartum period. To better understand the relationship of HYB curriculum and breastfeeding rates, this study should be replicated with more prenatal childbirth courses,

including various hospitals around the country.

Conclusion

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Appendix A

Breastfeeding Intervention Pre-Survey

Age: _____ Previous number of births: _______ Highest level of education: ____________

Estimated Due Date: _______________________

Email address: ______________________________________________

Marital Status? (please circle one) Single Committed Relationship Married

Have you taken a breastfeeding class before? No Yes

Do you have a friend and/or relative who successfully breastfed?

Friend: No Yes Relative: No Yes

How sure are you that you want to breastfeed? (please circle a number below)

Do NOT want to breastfeed WILL breastfeed no matter what

1 2 3 4 5 6 7 8 9 10

Explain why you chose this number:

If you do plan on breastfeeding:

Who will you call/reach out to for breastfeeding support? ___________________ How long do you intend to breastfeed? _______________________

Please answer 1-4 if you have already had a baby:

1. How did you feed your newborn 0-6months? (please circle one) Formula-fed Breastfed Combination of both

2. If you breastfed, how long did you breastfeed? (please circle one)

1-2 weeks 1-3months 3-6months 6-9months 9-12months

12-15months 15-18months 18-21months 21-24months 24+months

3. How old was your baby when you gave them food for the first time?

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For each of the following items, I want you to tell me how sure you are that you could do each of the things described:

Not at all sure

Slightly sure

Fairly sure

Very sure

Completely sure 1. I can find the information I need about

problems I have breastfeeding my baby. NS SS FS VS CS 2. I can find out what I need to know

about breastfeeding my baby. NS SS FS VS CS

3. I know who to ask if I have any questions about breastfeeding my baby.

NS SS FS VS CS

4. I can talk to my partner about the importance of breastfeeding my baby.

NS SS FS VS CS

5. I can talk to my health care provider about

breastfeeding my baby. NS SS FS VS CS

6. I can schedule my day around the

breastfeeding of my baby. NS SS FS VS CS

7. I can make the time to breastfeed

my baby even when I feel busy. NS SS FS VS CS

8. I can breastfeed my baby even

when I am tired. NS SS FS VS CS

when I am upset. NS SS FS VS CS

10. I can use a breast pump

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Not at all sure

Slightly sure

Fairly sure

Very sure

Completely sure 11.

I can prepare breastmilk so

others can breastfeed my baby. NS SS FS VS CS

if it causes mild discomfort. NS SS FS VS CS

13. I can breastfeed my baby

without feeling embarrassed. NS SS FS VS CS

14. I can breastfeed my baby when

my partner is with me. NS SS FS VS CS

my family or friends are with me. NS SS FS VS CS

around people I do not know. NS SS FS VS CS

17. I can call a lactation counselor

if I have problems breastfeeding. NS SS FS VS CS

18. I can choose to breastfeed my baby even

if my partner does not want me to. NS SS FS VS CS

if my family does not want me to. NS SS FS VS CS

20. _{I can breastfeed my baby for one year.}

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Appendix B

Breastfeeding Intervention Post-Survey

Email address: _______________________________

For each of the following items, I want you to tell me how sure you are that you could do each of the things described:

Not at all sure

Slightly sure

Fairly sure

Very sure

Completely sure 1.

I can prepare breastmilk so

others can breastfeed my baby. NS SS FS VS CS

if it causes mild discomfort. NS SS FS VS CS

without feeling embarrassed. NS SS FS VS CS

my partner is with me. NS SS FS VS CS

my family or friends are with me. NS SS FS VS CS

around people I do not know. NS SS FS VS CS

7. I can call a lactation counselor

if I have problems breastfeeding. NS SS FS VS CS

8. I can choose to breastfeed my baby even if my partner does not want

me to.

NS SS FS VS CS

if my family does not want me to. NS SS FS VS CS

10_{I can breastfeed my baby} for one year.

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Not at all sure

Slightly sure

Fairly sure

Very sure

Completely sure 11. I can find the information I need about

problems I have breastfeeding my baby. NS SS FS VS CS

12. I can find out what I need to know

about breastfeeding my baby. NS SS FS VS CS

13. I know who to ask if I have any questions about breastfeeding my baby.

NS SS FS VS CS

14. I can talk to my partner about the importance of breastfeeding my baby.

NS SS FS VS CS

15. I can talk to my health care provider about

breastfeeding my baby. NS SS FS VS CS

16. I can schedule my day around the

breastfeeding of my baby. NS SS FS VS CS

17. I can make the time to breastfeed

my baby even when I feel busy. NS SS FS VS CS

when I am tired. NS SS FS VS CS

when I am upset. NS SS FS VS CS

20. I can use a breast pump

to obtain milk. NS SS FS VS CS

How sure are you that you want to breastfeed? (please circle one)

Do NOT want to breastfeed WILL breastfeed no matter what

0 1 2 3 4 5 6 7 8 9 10